Download Index Universal Life withdrawal, loan or surrender request

Index Universal Life withdrawal, loan and surrender
request instructions and guidelines
General Information
Recurring Distributions
Print clearly using blue or black ink. Cross through and initial
any corrections or changes. Do not use correction fluid.
Recurring distribution requests must be received in our
office no less than 15 days prior to your desired start date.
The date of first distribution cannot be more than 30 days
from the date this request is signed.
This request applies to Genworth Index Universal Life
(IUL) products only. If you own a different product, please
download the correct form from genworth.com. If you have
questions regarding which form to choose, please call
customer service at 888 GENWORTH (436.9678).
You may request in-force illustrations demonstrating the
potential consequences of taking a single or recurring
disbursement.
Valid non-recurring disbursement and surrender requests
are processed within 10 business days of receipt in our office.
A letter confirming your distribution will be sent upon
processing your request. All distributions will be in the
form of a check sent under separate cover.
If you do not provide your Social Security or Tax ID number,
federal and any applicable state taxes may be withheld.
Distribution Information
Withdrawals
With sufficient policy value, you may withdraw an amount
equal to the premiums paid into the policy on an income
tax-free basis.
Withdrawals reduce:
• Policy value
Death benefit
• • Lifetime and monthly maximum amounts of the
Accelerated Benefit Rider for Long Term Care
Services (if present)
Once requested, distributions will recur automatically on
your desired frequency until:
• The final distribution date noted on this form
• You request them to stop
• Policy funds are insufficient to cover the recurring
amount
• Policy ownership is changed
• A collateral assignment is made
• An irrevocable beneficiary is designated
If you elect the Withdrawals to Basis followed by Loans
option, we will begin recurring withdrawals until you have
withdrawn the total of the Cost Basis. At that point, your
recurring disbursement will automatically switch to the
loan type you select.
If recurring distributions are stopped for any reason, we
require you to complete a new request to resume them.
Surrender
The net cash surrender value is the amount payable upon
surrender. Your coverage ends upon surrender of the
policy and cannot be reinstated.
Loans
Genworth IUL products offer two types of policy loans.
Carefully consider the types of policy loans prior to selection.
Participating/Collateral
• Eligible to receive index-linked crediting rates
• May amplify positive or negative policy
performance depending on the loan interest rate
charged and index-linked rate earned
Fixed Account
Taken from the Fixed Account value
• • If insufficient Fixed Account value exists, money will
be moved from index strategies on a pro-rata basis
Loan Switching
Only one type of loan may exist at a time. You may use this
request to pay off an existing loan and transfer the balance
to the opposite loan type. You may request such a transfer
once per policy year.
Genworth Life and Annuity Insurance Company, Richmond, VA
Genworth Life Insurance Company, Richmond, VA
160612INST 10/19/15
Genworth, Genworth Financial and the Genworth logo are registered service marks of Genworth Financial, Inc. © 2015 Genworth Financial, Inc.
All rights reserved.
Index Universal Life withdrawal, loan and surrender request instructions and guidelines
Signatures
Please review and follow the instructions below carefully to
ensure your request is not delayed.
Be sure to have all required parties, including irrevocable
beneficiaries and collateral assignees, sign in their capacity
or with title as required.
Due to the passage of time and how signatures change,
notarization is recommended but not required unless
the signature(s) on this request cannot be matched to the
signature(s) we have on file.
Attorney-in-Fact
The attorney-in-fact or Agent must sign in capacity as “attorney-in-fact” or
“Agent”, provide a copy of the entire power of attorney document (if not
previously submitted), and complete and submit a Genworth Declaration
of attorney-in-fact form. An updated Declaration of attorney-in-fact form is
required every 12 months if the power of attorney is durable, otherwise an
updated form is required with each request submitted.
Collateral Assignee
Any collateral assignee on the policy must sign authorizing the
request or submit a release of assignment dated prior to the request.
Corporation or Limited Liability Corporation (LLC)
An officer of the company or member of the LLC must sign with title (if the
signing officer or member is also the insured/annuitant, a second officer
or member must also sign), and provide either a corporate or board of
director’s resolution or a copy of the Articles of Incorporation or operating
agreement (for LLCs).
Guardian/Conservator
The guardian/conservator must sign in capacity and provide a copy of the
guardianship documents if not previously submitted.
Irrevocable beneficiary
The individual, trustee or representative must sign with the title
“Irrevocable Beneficiary”.
Joint owners
All owners must sign.
Partnership
All partners must sign with title, or the general or managing partner must
sign with title (if the general or managing partner is also the insured,
another partner must also sign).
Spouse
A spouse in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA,
WI) must sign.
Trust
The trustee(s) must sign with title “trustee”, according to the terms of the
Trust Agreement, and submit the Certification of Trustee Powers form if not
previously submitted within the past twelve months.
160612INST 10/19/15
Genworth Life & Annuity
Genworth Life
P.O. Box 40016
Lynchburg, VA 24506-4016
Tel: 888 GENWORTH (436.9678)
Fax: 877 300.1280
genworth.com
Index Universal Life withdrawal, loan and
surrender request
○ Genworth Life and Annuity Insurance Company (GLAIC)
○ Genworth Life Insurance Company (GLIC)
Page 1 of 3
• Complete the policy information section and either the withdrawal, loan or surrender section,
and sign on page 3
• Please print clearly using blue or black ink, and initial any corrections or we may not be
able to accept your request
Policy information
Policy number
Insured Date of birth
▪
▪
Insured name
Policy Owner Telephone number
▪
▪
Policy Owner Name
Policy Owner SSN/TIN
▪
▪
Policy Owner Mailing Address
▪
Important information
Withdrawals and outstanding
loan balances reduce the net cash
surrender value and death benefit
of the policy.
• Surrenders, withdrawals and loans may have significant tax consequences (please contact your
tax advisor).
• Refer to your policy for the maximum Withdrawal Amount.
• The request to borrow, surrender or withdraw any policy value may affect the guaranteed
elements, non-guaranteed elements, face amount or surrender value of the policy from which
the values are released.
Withdrawal Only complete this section if you want to take a non-recurring withdrawal from your policy.
If your policy has an Accelerated
Benefit Rider for Long Term Care
Services, a withdrawal reduces the
amount available under that rider.
Requested Withdrawal Amount Select one
○ Maximum Withdrawal Amount ○ Specify Withdrawal Amount $
A withdrawal reduces policy value. The net amount at risk remains the same after a withdrawal.
Tax withholding will affect the amount you receive.
Loan/Loan Switching Only complete this section if you want to take a non-recurring policy loan or switch loan type.
Loan type Select one
○ Participating/Collateral Loan ○ Fixed Account Loan
Requested Loan Amount Select one
○ Maximum amount available ○ Specify loan amount $
Gross or Net Loan Select one (Loan will be a gross loan if selection is not made.)
○ Gross. The amount you receive will have been reduced by any amount withheld for taxes if your
policy is a Modified Endowment Contract (MEC).
○ Net. You receive the amount requested.
Loan Type Switching If applicable, select one
○ Existing Fixed Account Loan switched to Participating/Collateral Loan
○ Existing Participating/Collateral Loan switched to Fixed Account Loan
Important information regarding
a Loan or Loan Switching
160612 10/19/15
• By requesting a loan, you agree to assign the policy listed on this request as sole security for the
loan. Terms for interest and repayment of the loan are subject to the provisions of the policy.
• Requesting a maximum loan may cause your policy to enter a grace period and lapse.
• Your policy allows two types of loans: a Participating/Collateral Loan or a Fixed Account Loan.
Only one type of loan may exist at a time.
• Loan switching: Loan switching is the ability to switch loan types without having to use funds
external to the policy to pay off the balance of one type before taking a loan of the other type.
• The loan balance of one type is transferred to a new loan of the other type.
The amount of the new loan is the payoff amount for the old loan on the day
before the new loan is made.
• A loan switch is allowed only once per policy year.
• A loan switch will not be processed on the 14th or 15th of any calendar month
or on a policy anniversary.
Index Universal Life withdrawal, loan and surrender request
Page 2 of 3
Recurring withdrawals and loans
Tax withholding will affect the
amount you receive.
Recurring distributions must be
requested no less than 15 days prior
to the first scheduled distribution
or processing may be delayed.
The date of first distribution
cannot be more than 30 days from
the date this request is signed.
Type of Distribution
○ Withdrawals ○ Loans* ○ Withdrawals to Basis followed by Loans*
Amount $
Frequency ○ Monthly
○ Quarterly
○ Semi-Annually
○ Annually
Date of First Distribution: (mm/dd/yyyy)
Date of Final Distribution: (mm/dd/yyyy)
*Provide the following information if your distribution includes Loans.
Loan type Select one
○ Participating/Collateral Loan ○ Fixed Account Loan
Gross or Net Loan Select one (Loan will be a gross loan if selection is not made.)
○ Gross. The amount you receive will have been reduced by any amount withheld for taxes
if your policy is a Modified Endowment Contract (MEC).
○ Net. You receive the amount requested.
Surrender Only complete this section if you want your policy to end
Upon surrender, you may return
your policy to the company, but
we do not require you to do so. By
signing and sending this form to the
company, you agree that the company
may immediately process surrender
without return of your policy.
○ Check here to surrender your policy. Make sure that you read the following important
information before you consider surrendering your policy:
• Life insurance coverage ends upon surrender. You cannot change your mind once you send us
notice to surrender. The policy does not provide for a grace period after surrender.
• The amount payable upon surrender is the policy’s net cash surrender value.
Tax information
• If your policy is a MEC, withdrawals, loans and surrenders will be taxable income-first and, if taken before age 59 1/2, may be subject to
a 10% penalty tax.
• Withholding only applies to the taxable portion of the payment you receive.
• If the policy is surrendered with an outstanding loan balance prior to payment of the death benefit, the taxable portion will include the
loan balance on the surrender date.
• Unless you elect not to have any taxes withheld, federal withholding is generally at a 10% rate.
• If you elect not to have federal and state income tax withheld, you are still liable for payment of federal income tax and, if applicable, state
income tax on the taxable portion of the distribution. You may also be subject to tax penalties under the Estimated Tax Payment Rules
if any payments of estimated tax and withholding are insufficient (IRS Publication 505 explains federal estimated tax requirements and
describes penalties in detail). You may be able to avoid quarterly tax payments by having enough tax withheld from your withdrawals.
• If your policy is not a MEC, loans will be taxable only if the policy terminates with an outstanding loan balance prior to payment of the
death benefit.
• If your policy is a MEC, loans will be treated for income tax purposes as withdrawals from a MEC. Any loan interest that is not paid will
be treated as an additional loan. Your cost basis will be increased to reflect any taxable income reported with respect to policy loans.
• If you are considering taking a loan, withdrawal or surrender with respect to a MEC or are concerned about the effect of any policy transaction
on your estate plan or other aspects of your personal tax situation, you are strongly advised to consult a tax advisor.
Tax withholding information
You don’t need to complete this
section for a loan unless your policy
is a MEC.
If the distribution is subject to tax
we will withhold federal and any
applicable state taxes if you do not
complete this section.
If no state tax amount or percent is
specified, no state income tax will
be withheld, unless required by
the state.
This is a high level summary of
our understanding of state tax
withholding. You should consult
your tax advisor or your state’s
website for specific withholding
information.
160612 10/19/15
• In MI state withholding is required, regardless of federal withholding, unless you elect
not to have taxes withheld (MI requires you to complete Form MI W-P). If federal tax is not
withheld, all states that otherwise require withholding will permit you to select a dollar amount
or percentage of state tax to be withheld.
• If you want state income tax withheld in AL, AR, CO, CT, DC, DE, GA, ID, IL, IN, KY, LA,
MD, MN, MO, MT, ND, NJ, NM, NY, OH, PA, RI, SC, UT, WI and WV you must designate a
state withholding amount.
• In IA, KS, MA, ME, NE, OK and VT if federal withholding is required then state
withholding is required at the current state rate or higher amount you choose.
• We cannot withhold state income tax in AK, AZ, FL, HI, MS, NH, NV, SD, TN, TX, WA and WY.
• Unless you elect not to have state Income tax withheld in CA, NC, OR or VA state
withholding is required at the current rate or higher amount you choose.
• If applicable, the state withholding certificate may state special rules and conditions for
withholding state Income tax.
• Special withholding rules and forms apply to payments delivered overseas or to non-residents of
the United States.
Withhold federal taxes Select one
If yes, specify amount (minimum of 10%) Select one
○ Yes
○ $
○ No
Withhold state taxes Select one
○ No
○ Yes
○
%
If yes, specify amount or percentage (or default to
state tax regulation) Select one
○ $
○
%
If you do not provide your Social Security or Tax ID number (see Substitute Form W-9 section) up to
30% federal and any applicable state taxes will be withheld. For your protection, your distribution may
be delayed while the company attempts to confirm your identity and intentions as to withholding.
Index Universal Life withdrawal, loan and surrender request
Page 3 of 3
Substitute Form W-9 (an official Form W-9 with instructions is available upon request)
If you are not a U.S. citizen or
other U.S. person, do not complete
this section. You must provide an
IRS Form W-8BEN (individual),
W-8BEN-E (non-individual), or
another applicable IRS form to
document your foreign status.
Check appropriate box for federal tax classification:
You must cross out item 2, if you
have been notified by the IRS that
you are currently subject to backup
withholding because of a failure to
report all interest and dividends
on your tax return.
Social security number or Employer identification number :
The Foreign Account Tax
Compliance Act (FATCA) is a Federal
tax regulation that extends existing
reporting requirements to require
Foreign Financial Institutions to
comply with IRS request of
withholding and reporting on U.S.
and unidentified account holders.
IRS regulations require certification
of FATCA exemption. FATCA
codes apply to certain entities,
not individuals.
○ Individual/sole proprietor
○ C Corporation
○ S Corporation
○ Partnership
○ Trust/estate
○ Limited liability company
Enter the tax classification (C=C corporation, S=S corporation, P=partnership):
○ Other (see instructions):
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for
a number to be issued to me), and
2. I am not subject to backup withholding because:
(a) I am exempt from backup withholding, or
(b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup
withholding as a result of a failure to report all interest or dividends, or
(c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined in the instructions).
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA
reporting is correct.
Signature of U.S. person
Date
X
▪
Declaration and signature(s)
• You must sign in capacity or with title and provide documentation of authority unless signing as an individual.
• My signature indicates that I have read and understand all sections of this form.
• I declare that I am not involved in any bankruptcy proceedings.
Current owner Required
Date
Capacity ◯ Individual ◯ Trustee ◯ Guardian
X
▪
◯ Attorney-in-Fact ◯ Title/officer:
Joint owner If applicable, required
Date
Capacity ◯ Individual ◯ Trustee ◯ Guardian
X
▪
◯ Attorney-in-Fact ◯ Title/officer:
Other If applicable
Date
Capacity ◯ Individual ◯ Trustee ◯ Guardian
X
▪
◯ Attorney-in-Fact ◯ Title/officer:
Consenting party If applicable, required
Date
X
▪
Capacity ◯ Collateral Assignee
◯ Irrevocable Beneficiary
◯ Spouse
Notarial statement
State of
County/ City of
On this
day of
, 20
, before me, personally appeared
known to me or satisfactorily proved to me to be the person who signed the above document, and acknowledged that he/she executed the
document.
Notary Public:
160612 10/19/15
My commission expires: